1997 Exam II Case 02

Chief Complaint:

This is a 65 year old right-handed woman complaining of weakness and sensory loss.

History of Chief Complaint:

She has experienced periods of dizziness and nausea over the past three weeks. On the day of admission she had had an emotional argument with her daughter-in-law. Shortly thereafter she experienced a severe bifrontal headache, dizziness and a noticeable loss in strength of her right arm and leg.

Medical History:

She is positive for hypertension and artherosclerosis. She has a 20 pack-year history of smoking. Surgical History: none Allergies: none

Medications: none

Physical Exam:

Blood pressure is 140/90, respiratory rate is 22 and heart rate is 92. Neck is supple, a soft carotid bruit is heard over the left carotid artery. Heart rate is regular without murmurs. Lungs have faint inspiratory wheezes bilaterally which improve somewhat with coughing. Abdomen is soft without tenderness, rebound or rigidity. No abdominal bruits are noted.

Neurologic Exam:

Mental Status: She is awake and oriented to person, place and time. She is aware of her condition. Her speech is clear and meaningful. Her memory and fund of knowledge is appropriate. She can follow two and three step commands with her left arm. She is an accurate historian.

Cranial nerves: Her visual fields are full on the left and completely absent on the right. She can see nothing to the right of the midline. She is aware of this deficit. Both pupils respond to light. She has a full range of eye movements. She responds to touch and pin prick throughout her face. Her facial expressions are full and symmetric. Hearing is intact to finger rub. Her palette elevates on the midline and her tongue protrudes on the midline.

Motor exam: Her power is 5/5 in the left extremities. In the right, her power is 2/5 at the shoulder and thigh and 1/5 at the elbow, wrist, fingers, knee and ankle. There are no adventitious movements.

Reflexes: Deep tendon reflexes are 2/4 in the left extremities. On the right, the deep tendon reflexes are 3/4 at the biceps, triceps and knee and 4/4 at the brachioradialis and ankle.

Sensory: She responds to touch and pin prick throughout her body and extremities. Position sense is intact in the extremities bilaterally.

Follow-Up:

Examination at one year post stroke finds the right visual field defect has completely cleared. Power is 4/5 in the right arm and leg. However, a significant movement disorder is now present. The right extremities have a continuous wild, flinging movement. Her gait is abnormal due to the continuous aberrant motions of the leg that cause her to stumble. Attempts to stabilize the right extremities are useless. This random movement of her extremities ameliorates when she is sleeping. Currently she has been placed on a neuroleptic drug to attempt to suppress the unwanted motion.

Questions

INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.

Question 01:

The visual defect expressed in this patient is best termed:

a) Monocular blindness

b) Bitemporal hemianopsia

c) Homonymous hemianopsia

d) Homonymous hemianopsia with macular sparing

e) Visual neglect

ANSWER

Question 02:

The visual defect expressed in this patient is most likely due to a lesion of the:

a) Optic nerve

b) Optic chiasm

c) Optic tract

d) Lateral geniculate nucleus

e) Visual cortex

ANSWER

Question 03:

The motor defect initially expressed in this patient is best termed:

a) Spastic paresis

b) Spastic praxis

c) Apraxic hemiparesis

d) Astasia

e) Athetosis

ANSWER

Question 04:

The motor defect initially expressed in this patient is most likely due to a lesion of the:

a) Motor cortex

b) Corona radiata

c) Internal capsule

d) Crus cerebri

e) Subthalamic nucleus

ANSWER

Question 05:

The motor defect expressed by the patient one year post stroke is best termed:

a) Flaccid paralysis

b) Hemiballism

c) Hemichorea

d) Athetosis

e) Apraxia

ANSWER

Question 06:

The motor defect expressed by the patient one year post stroke is most likely due to a lesion of the:

a) Premotor cortex

b) Corpus callosum

c) Putamen

d) Subthalamic nucleus

e) Ventrolateral nucleus

ANSWER

Question 07:

In this patient, chomatolytic cell bodies will most likely be present in the:

a) Globus pallidus internus

b) Globus pallidus externus

c) Ventroanterior thalamic nucleus

d) Caudate

e) Substantia nigra

ANSWER

Question 08:

In this patient, degenerating axons will most likely be present in the:

a) Dentothalamic fibers

b) Striatopallidial fibers

c) Nigrostriatal fibers

d) Corpus callosum

e) Subthalamopallidial fibers

ANSWER

Question 09:

The most likely location for this lesion on the neuraxis is:

a) Supplementary motor cortex

b) Internal capsule

c) Ventral thalamus

d) Crus cerebri

e) Premotor cortex

ANSWER

Question 10:

The best description of the distribution of this lesion is:

a) Focal and on the left

b) Focal and on the right

c) Multifocal

d) Diffuse

ANSWER

Question 11:

The best description of the temporal profile of this lesion is:

a) Acute and stable

b) Acute and progressive

c) Chronic and stable

d)Chronic and progressive

ANSWER

Question 12:

Imaging studies of this patient would be expected to demonstrate an occlusion in the penetrating branches of the:

a) Anterior cerebral artery

b) Middle cerebral artery - upper division

c) Middle cerebral artery - lower division

d) Posterior cerebral artery

e) Posterior choroidal artery

ANSWER